request for medical record screening...contact no. address: request for medical record screening...

4
Dear Doctor I am currently applying for a firearm and/or shotgun certificate / registration as a firearms dealer. I am required to supply factual medical information from my GP to accompany my application form. I realise a fee may be payable which I am willing to pay and that the report will not be produced until the appropriate fee has been paid. Please find enclosed pro-forma for completion by my GP. The form is requesting factual medical information only relating to the relevant medical conditions as listed. I am advised by the Police that the provision of a simple print out of my medical history will not be acceptable for this purpose. Furthermore, can I please request that only information relating to the relevant medical conditions impacting upon my suitability to possess firearms and shot guns are commented upon. Please note that the Police are NOT seeking your professional opinion on my health and wellbeing and are not asking you to make a decision on whether I am granted a certificate. The responsibility to make this decision lies solely with the police. Once the attached pro-forma has been completed, please contact me in order for me to collect it. CONSENT: I give the police permission to contact my GP and/or specialist to obtain factual details of any medical history in relation to my suitability to possess a firearm and/or shot gun. This authority is valid for the life of the certificate(s). I understand that my GP may share sensitive personal data with the police concerning my physical and mental health for the purposes of enabling the police to make a fully informed decision on my application and continued suitability and I hereby consent to this processing of my personal data. Your GP Name: GP / Practice address: Date: Signed: Patients full name: Date of Birth: Contact No. Address: Request for Medical Record Screening

Upload: others

Post on 05-Jul-2020

2 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Request for Medical Record Screening...Contact No. Address: Request for Medical Record Screening Firearms Licensing Standardised Medical Information Proforma Any attempt at amending

Dear Doctor

I am currently applying for a firearm and/or shotgun certificate / registration as a firearms dealer.

I am required to supply factual medical information from my GP to accompany my application form. I realise a fee may be payable which I am willing to pay and that the report will not be produced until the appropriate fee has been paid.

Please find enclosed pro-forma for completion by my GP. The form is requesting factual medical information only relating to the relevant medical conditions as listed. I am advised by the Police that the provision of a simple print out of my medical history will not be acceptable for this purpose.

Furthermore, can I please request that only information relating to the relevant medical conditions impacting upon my suitability to possess firearms and shot guns are commented upon.

Please note that the Police are NOT seeking your professional opinion on my health and wellbeing and are not asking you to make a decision on whether I am granted a certificate. The responsibility to make this decision lies solely with the police.

Once the attached pro-forma has been completed, please contact me in order for me to collect it.

CONSENT:

I give the police permission to contact my GP and/or specialist to obtain factual details of any medical history in relation to my suitability to possess a firearm and/or shot gun. This authority is valid for the life of the certificate(s). I understand that my GP may share sensitive personal data with the police concerning my physical and mental health for the purposes of enabling the police to make a fully informed decision on my application and continued suitability and I hereby consent to this processing of my personal data.

Your GP Name:

GP / Practice address:

Date:

Signed:

Patients full name:

Date of Birth:

Contact No.

Address:

Request for Medical Record Screening

Page 2: Request for Medical Record Screening...Contact No. Address: Request for Medical Record Screening Firearms Licensing Standardised Medical Information Proforma Any attempt at amending

Firearms Licensing Standardised Medical Information Proforma

Any attempt at amending this form after the GP has completed it is a criminal offence under Section 28A (7) of the Firearms Act. If you knowingly or recklessly make a false statement for the purpose of procuring the grant or renewal of a certificate, the maximum penalty is six months imprisonment and/or a fine.

PATIENTS DETAILS

Title: Full Name:

Home Address:

Date of Birth (DD/MM/YYYY):

MEDICAL INFORMATION To be completed by GP

Please check the patient's medical record for any history of the following and tick those that apply. Where any apply, please add further details overleaf which can be limited to statement of fact and not an opinion.

Have you had access to the patient’s full medical records to complete this report? Yes n No n

DATE RECORDS BEGIN: DATE OF LAST CONSULTATION:

Acute stress reaction, or an acute Yes n No n reaction to the stress caused by a trauma

Suicidal thoughts or thoughts Yes n No n or threat of self-harm

Depression or anxiety Yes n No n

Dementia Yes n No n

Mania, bipolar disorder or Yes n No n psychotic illness

Diabetes Yes n No n

Personality disorder Yes n No n

Any severe neurological impairment Yes n No n (e.g. MS, Parkinson's, Huntington's or epilepsy, or any condition which has required consultation by a neurologist)

Alcohol or drug abuse Yes n No n

Stroke Yes n No n

Terminal illness within the last 2 years Yes n No n

Does the Patient suffer with any Yes n No n condition which affects their suitability to hold a driving licence?

Cymru Wales

PLEASE SIGN OVERLEAF AND PROVIDE FURTHER INFORMATION IF YOU HAVE TICKED YES TO ANY OF THE ABOVE QUESTIONS.

CONFIDENTIAL – MEDICAL (when complete)

WMF1 Form

1

Page 3: Request for Medical Record Screening...Contact No. Address: Request for Medical Record Screening Firearms Licensing Standardised Medical Information Proforma Any attempt at amending

CONFIDENTIAL – MEDICAL (when complete)

FURTHER DETAILS Continued from previous page - if applicable:

What is the medical condition?

How long has the patient been treated for this condition?

Is the patient still being treated for this condition?

Details of medication prescribed

Has there been any previous episodes of this condition?

What is the patients current condition?

Do you have any other information you believe may be relevant to the police in determining whether the patient is safe to possess firearms?

Name of GP:

Signature of GP:

GMC Number:

Date:

Practice stamp:

WMF1 Form

2

Page 4: Request for Medical Record Screening...Contact No. Address: Request for Medical Record Screening Firearms Licensing Standardised Medical Information Proforma Any attempt at amending

GUIDANCE NOTES

The applicant should fill in their personal details and then request their GP complete the rest of the form.

A fee may be charged by the GP prior to completion.

INTRODUCTION: In conjunction with the Police forces of South Wales, Gwent, North Wales & Dyfed Powys and the Wales - British Medical Association, this form and medical process has been devised to:

Maximise public safety

Minimises workload upon both the Firearms Licensing Department and GPs

Provides clarity and consistency to applicants across Wales

DATA PERIOD: In the interest of public safety, records should be checked as far back as records in the possession of the GP go, with paper records checked where present. GPs should also specify the date of the first entry in the records in the box provided.

FEES: BMA guidance makes it clear that providing medical information for shotgun or firearm certificates is not NHS work and falls outside the contractual obligations of GPs. Thus, GPs are entitled to remuneration for this work and may withhold the work until payment is made. Such a fee must be paid by the applicant.

FURTHER REPORTS: Occasionally, when required, following the receipt of this form the Police may need to contact other clinicians such as consultants for a specialist opinion. Such reports fall outside the scope of this form and are not the responsibility of the GP to source. The Police may also write to the GP during the life of a certificate requesting factual medical information, the Police will pay for this report.

FLAGS: Home Office Guidance to the Police (Firearms Licensing) asks GPs to place a firearm reminder code on the patient's record. This permits the on-going review of suitability to possess firearms, should medical issues arise. The police will notify GP’s when a certificate has been issued in order that a ‘flag’ can be applied to the patient’s medical record.

RESPONSIBILITY: It remains the ultimate responsibility of the Police to decide on the grant/refusal of any shotgun or firearm certificate. The role of the GP is information provision by way of statement of fact only.

CONSCIENTIOUS OBJECTION: BMA guidance requires GPs to take reasonable steps to notify their patients of their conscientious objection in advance and they would advise doctors who hold such beliefs, to ensure a clear statement to this effect is placed on their website and on notices in public areas of the practice.

In their view conscientious objectors are not required to arrange for an alternative provision of such a report. Where access to a firearm is a professional requirement, such as gamekeepers and farmer, they would nonetheless encourage doctors to assist applicants in identifying a suitable colleague willing to engage in the firearms certification process.

AUDIT: In the interests of public safety, the Police reserve the right to check the accuracy of forms from time to time with the GP who completed it.

WMF1 Form

3